elias mir kualitas hidup anak rhinitis alergi

8/16/2019 Elias Mir Kualitas Hidup Anak Rhinitis Alergi

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Asia Pacific

allergypISSN 22338276 eISSN 22338268

Current Reviewhttp://dx.doi.org/10.5415/apallergy.2012.2.2.93

Asia Pac Allergy 2012;2:93-100

Impact of allergic rhinitis in school going childrenElias Mir, Chandramani Panjabi

†, and Ashok Shah

*

Department of Respiratory Medicine, Vallabhbhai Patel Chest Institute, Universit y of Delhi, Delhi 110 007, India

Allergic rhinitis (AR) is the most common chronic pediatric disorder. The International Study for Asthma and Allergies in Childhood

phase III found that the global average of current rhinoconjunctivitis symptoms in the 13-14 year age-group was 14.6% and the average

prevalence of rhinoconjunctivitis symptoms in the 6-7 year age-group was 8.5%. In addition to classical symptoms, AR is associated

with a multidimensional impact on the health related quality of life in children. AR affects the quality of sleep in children and frequently

leads to day-time fatigue as well as sleepiness. It is also thought to be a risk factor for sleep disordered breathing. AR results in increased

school absenteeism and distraction during class hours. These children are often embarrassed in school and have decreased social

interaction which significantly hampers the process of learning and school performance. All these aspects upset the family too. Multiple

co-morbidities like sinusitis, asthma, conjunctivitis, eczema, eustachian tube dysfunction and otitis media are generally associated

with AR. These mostly remain undiagnosed and untreated adding to the morbidity. To compound the problems, medications have

bothersome side effects which cause the children to resist therapy. Children customarily do not complain while parents and health

care professionals, more often than not, fail to accord the attention that this not so trivial disease deserves. AR, especially in developing

countries, continues to remain a neglected disorder.

Key words: Allergic rhinitis; Asthma; Learning disability; Pediatric; Quality of life; School children; Sinusitis; Sleep disturbances

INTRODUCTION

The Allergic Rhinit is and its Impact on Asthma (ARIA) 2008

updated document estimates that there are 500 million subjects

in this world who suffer with allergic rhinitis (AR) [1]. Data

suggests that AR is the most common chronic disorder in the

pediatric population with up to 40% of children affected [1]. The

disease along with associated co-morbidities has a profound

impact on the daily lives of children. Irritability, sadness,

impairment of sleep and limitation of activities at school as well

as home are often seen in these children. AR results in day-time

fatigue and impairment of cognition and memory in children

Correspondence: Ashok ShahDepartment of Respiratory Medicine, Vallabhbhai Patel Chest

Institute, University of Delhi, Delhi 110 007, P.O. Box 2101,

India

Tel: +91-11-2543-3783

Fax: +91-11-2766-6549

E-mail: [email protected]

†Current affiliation: Department of Respiratory Medicine,

Mata Chanan Devi Hospital, New Delhi, India

Received: April 3, 2012Accepted: April 7, 2012

This is an Open Access article distributed under the terms of the Creative

Commons Attribution. Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use,

distribution, and reproduction in any medium, provided the original work is

properly cited.

Copyright © 2012. Asia Pacific Association of Allergy, Asthma and Clinical Immunology.

http://apallergy.org


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which significantly affect the learning process and thus impacts

on school performance and all these aspects upset the family

[2]. Many of these problems go completely unnoticed as children

often fail to share them at home or at school. Furthermore,adverse effects of medications used for treatment of AR often

compound these problems [2]. Although AR greatly impacts life

at home, school and even while sleeping, it is treated as a trivial

and a commonplace disorder. Consequently, it does not receive

the attention it deserves from the patient, the family as well as the

health care professionals, especially in developing countries like

India [3].

Burden of allergic rhinitis in children of the Asia-Pacific

region

The International Study for Asthma and Allergies in Childhood

(ISAAC) phase III [4] found that the global average of current

rhinoconjunctivitis symptoms in the 13-14 year age-group was

14.6% and the average prevalence of rhinoconjunctivitis symptoms

in the 6-7 year age-group was 8.5%. The prevalence of AR in

certain centres approached more than 50%. Higher prevalence of

severe rhinoconjunctivitis was seen in lower and middle income

countries particularly in Africa and Latin America [4]. In India, the

ISAAC phase I [5] revealed that 12.5% children in the 6-7 year age-

group and 18.6% in the 13-14 year age-group had nasal symptoms

alone, while allergic rhinoconjunctivitis was seen in 3.2% and 6.3%

children in these age-groups respectively. In ISAAC phase III [4],

the prevalence of current nose symptoms increased to 12.9% and

23.6% in the 6-7 and 13-14 year age-groups respectively, while the

prevalence of allergic rhinoconjunctivitis increased to 3.9% and10.4% respectively. Among the Asia- Pacific countries, the ISAAC

phase III data [4] revealed that allergic rhinoconjunctivitis was

lowest in Indonesia with prevalence ranging from 3.6% in the 6-7

year age-group to 4.8% in the 13-14 year age-group. In contrast,

the highest prevalence was documented in Taiwan which ranged

from 24.2% in the 6-7 year age-group to 17.8% in the 13-14 year

age-group [4]. Most countries in this region showed an increase in

the prevalence of allergic rhinoconjunctivitis between the ISAAC

phase I and III studies (Table 1) [6]. In an 11 Asian countries study

in selected centers, the prevalence of AR ranged from 10 to 46%

in children and was more common in boys [7]. Several studies of

AR in children from Asia confirm the enormity of burden of this

disease. In Taiwan, the mean one-year and overall 8-year (2000

to 2007) prevalence of AR in children and adolescents was 11.3%

and 37.8% respectively [8]. Similarly in China, a study in 24,290

children showed that the prevalence ranged from 7.83% to 20.42%

[9]. However, the ISAAC phase III study in Tibet [10] revealed

that allergic rhinoconjunctivitis was present in 5.2% of the 3196

children in the 13-14 year age-group. The authors state that this

was the lowest prevalence in the ISAAC phase III study worldwide

[10].

Table 1. Prevalence (%) of the symptoms of allergic rhinoconjunctivitis in children of Indian subcontinent, Asia-Pacific and the Oceanic

countries during the ISAAC phases I and III

ISAAC phase I ISAAC phase III

Age-group 6-7 years 13-14 years 6-7 years 13-14 years

India 3.2 6.3 3.9 10.0

Hong Kong 13.7 24.0 17.7 22.6

Indonesia 3.8 5.3 3.6 4.8

Japan 7.8 14.9 10.6 17.6

Malaysia 4.1 13.9 4.8 16.2Philippines - 15.3 - 11.1

Singapore 8.5 15.1 8.7 16.5

South Korea 9.8 10.2 8.7 11.6

Taiwan 14.6 11.7 24.2 17.8

Thailand 7.3 15.5 10.4 21.0

China - 8.1 - 10.4

Austrailia 9.8 - 12.9 -

New Zealand 9.5 19.1 11.4 18.0

Adapted from reference [6]. ISAAC, International Study for Asthma and Allergies in Childhood.


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Clinical profile of the patients and classification

The ARIA update 2008 [1] classifies AR on the basis of frequency

and severity. Mygind [11] first proposed classifying AR on the basis

of predominant clinical symptoms. He proposed calling those withpredominant blockage as ‘blockers’ and those with runny nose

as ‘sneezers and runners’ [11]. We sketched the profile of these

two clinical presentations in 114 adults with AR [12] and found

that almost two-third 72/114 (63%) were ‘sneezers and runners’

while 42/114 (37%) were ‘blockers’. ‘Sneezers and runners’ had

significantly more sneezing, rhinorrhoea, itchy nose, eyes and

palate. This group had a significantly more family history of atopy,

seasonal disease and sensitivity to seasonal allergens like pollen.

In contrast, ‘blockers’ had significantly more nasal blockade,

thick nasal mucus, and post nasal drip. In addition, ‘blockers’ had

significantly more sensitisation to perennial allergens like fungi

and house dust mite and had perennial disease [12]. Recently, we

evaluated 126 school going children with AR and/or asthma, of

whom 14 (11.1%) had AR only, 100 (79.3%) had concomitant AR

and asthma, while 12 (9.5%) had only asthma. On categorisation,

46 (40.4%) were classified as ‘sneezers and runners’ while 68 (59.6%)

were classified as ‘blockers’. ‘Sneezers and runners’ had more

sneezing (100% vs. 85.3%) and itchy nose (63% vs. 54.4%), while

‘blockers’ had more persistent disease (52.9% vs. 32.6%), post

nasal drip (67.6% vs. 54.3%), loss of smell (22.1% vs. 10.9%), loss of

taste (20.6% vs. 10.9%) and nasal quality of voice (14.7% vs. 4.3%).However, the differences did not achieve significance. On CT-PNS,

sinusitis (Fig. 1) was recorded in 78/126 (61.9%) children [13].

Sleep disturbances

Both adults and children with AR have disturbances in sleep.

Although the exact mechanisms of sleep impairment due to AR is

not known, uncontrolled symptoms especially nasal congestion

are thought to be responsible. The medications used may also

compound the problems [14-17]. In a study in 39 children with

habitual snoring, 14 (36%) had a positive radioallergosorbent testfor allergens [14]. Children with atopy had higher prevalence of

obstructive sleep apnea syndrome (OSAS) (57% vs. 40%; x2 = 9.11,

p < 0.01). The authors postulated that allergy was a risk factor for

the presence of OSAS in the children [14]. A questionnaire based

survey in Greece [15] involving parents of 3,680 children revealed

that habitual snoring was present in 5.3%, 4%, and 3.8% in the

children of 1-6, 7-12, and 13-18 year age-groups respectively.

This study also found that chronic rhinitis was one of the most

important risk factors for habitual snoring (odds ratio [OR] =

2.1, confidence interval [CI] = 1.6-2.7). Intranasal corticosteroids

(INCS) usage in children with AR appears to have an objective

improvement in sleep parameters on polysomnography with a

decrease of mean number of sleep arousals per h from a baseline

of 8.4 to 1.2 ( p = 0.005) [16]. In our study [13], parents reported

sleep disturbances in 70/114 (61.4%) school going children with

AR. Problems with sleep would heighten daytime somnolence and

impair cognition which in turn may result in behavioral problems [2,

17, 18].

Learning disabilities and problems at school

The symptoms of AR like nasal blockade, itching, rhinorrhoea

and sneezing cause severe distraction during class hours.

Uncontrolled symptoms at night leading to sleep loss and

secondary daytime fatigue may also contribute to learning

impairment similarly. Apart from absenteeism from the class,

even when present during class hours, the child has decreased

productivity. Complications of AR like sinusitis, eustachiandysfunction and associated conductive hearing loss may enhance

the learning dysfunction [2]. Irritability, distraction, fatigue increase

absenteeism and along with embarrassment at the school result

in impaired school performance in these children. This can be

compounded by the side effects of medication used for AR. The

recreational activities of children with AR are often limited which

leads to diminished social interaction and consequent isolation

[2, 17]. Even in adults with AR there is slow speed of cognitive

processing and impairment in working memory during the

Fig. 1. Coronal CT of the paranasal sinuses in a 7-year-old child showing

extensive mucosal thickening within all paranasal sinuses, ostiomeatal

complexes and nasal cavity.


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AR rarely occurs in isolation and is associated with multiple

co-morbidities. A close relation between AR and asthma is

well documented [29]. Symptoms of rhinitis were observed

in 28 to 78% of asthmatics, while 17-38% patients with ARhad concomitant asthma [30]. A questionnaire based study

conducted by us [31] showed that 75% of 405 children with

asthma had coexistent rhinitis. Simultaneous occurrence of

both the diseases was recorded in about three fourths of these

children [31]. A retrospective analysis [32] has shown that children

with AR younger than 7 years were at a 2 to 7 times greater risk

of developing asthma. The occurrence of AR in children also

increased the risk of persistence of childhood asthma by middle

age [32].

In the ISAAC phase III study in the Indian subcontinent [4],

among the 50,106 children in the age-group of 6-7 years, 1,183

(2.4%) had symptoms of rhinoconjunctivitis alone, 554 (1.1%) had

symptoms of both rhinoconjunctivitis and asthma, 174 (0.3%)

had symptoms of rhinoconjunctivitis and eczema, and 174 (0.3%)

had symptoms of all the three conditions. Among the 55,815

children in the age-group of 13-14 years, 4,177 (7.5%) children had

symptoms of rhinoconjunctivitis alone, 900 (1.6%) had symptoms

of both rhinocinjunctivitis and asthma, 496 (0.9%) had symptoms

of rhinoconjunctivitis and eczema, and 395 (0.70%) had symptoms

of all three conditions. In other countries of the Asia Pacific region,

of the 60,052 children in the age-group of 6-7 years, 3,520 (6.2%)children had symptoms of rhinoconjunctivitis alone, 1,117 (2.0%)

had symptoms of both rhinocinjunctivitis and asthma, 884 (1.5%)

had symptoms of rhinoconjunctivitis and eczema, and 494 (0.9%)

had symptoms of all three conditions. Similarly in the age-group of

13-14 years, among the 99,688 children, 8,581 (9.3%) children had

symptoms of rhinoconjunctivitis alone, 2,135 (2.3%) had symptoms

of both rhinocinjunctivitis and asthma, 1,064 (1.1%) had symptoms

of rhinoconjunctivitis and eczema, and 530 (0.60%) had symptoms

of all three conditions [4].

As highlighted in the ISAAC study, AR is commonly associatedwith conjunctivitis [4, 6]. The exact prevalence of allergic

conjunctivitis in children with AR cannot be determined as the

patients usually do not self report eye symptoms and do not

attach much importance to it [1]. A study from China revealed

that 430/485 (89%) children with AR had concomitant allergic

conjunctivitis [33]. Allergen exposure of nasal or conjunctival

mucosa may lead to inflammation at both the places probably

due to anatomical contiguity. Intranasal corticosteroids have been

shown to suppress nasal as well as ocular symptoms [34].

Patients with perennial AR are at a larger risk of developing

sinusitis [35]. At our Institute, we found that 136/189 (72%) of

subjects with AR had concomitant sinusitis [36]. The presence of

sinusitis increased the morbidity in patients with AR especially in‘blockers’ and increased the incidence of postnasal drip (62/88 vs.

15/43, p < 0.05) as well as sneezing (52/88 vs. 7/43, p < 0.05) [36].

Since sinusitis rarely occurs without rhinitis, the term ‘rhinosinusitis’

is frequently being used interchangeably with the term ‘rhinitis’ [1].

Patients with AR also have a higher incidence of nasal polyposis

which is considered to be a part of spectrum of chronic sinus

pathology [37].

Allergy should be investigated in children with symptomatic

adenoid hypertrophy [1]. Although the exact role of allergy in

adenoid hypertrophy is unknown; the presence of sensitisation to

inhalant allergens has been reported to alter the immunology of

adenoid tissue which might have an aetiological role in adenoid

hypertrophy [38]. Inflammation in AR can lead to mucosal swelling

around eustachian tube. Tympanometery performed in 80 patients

with AR and 50 healthy controls, comprising adults and children,

demonstrated abnormalities in 15.5% of children below 11 years

of age with AR [39]. In contrast, no abnormal curves were seen in

healthy controls; thereby demonstrating that children with AR are

at a greater risk of Eustachian dysfunction [39]. The presence of

rhinitis or atopic eczema is significantly associated with a higher

incidence of otitis media with effusion [38, 40].

Treatment issues

The goals of management of AR, as des cribed in the ARIA

management pocket reference guide [41], include (i) no

troublesome symptoms, (ii) performance of near normal daily

activities without school absenteeism, (iii) no sleep impairment,

and (iv) minimal or no side-effects of treatment. Allergen

avoidance along with pharmacotherapy is the mainstay of

treatment. Key allergens should be identified and avoided as far as

possible. Oral/intranasal antihistamines along with INCS comprisethe armamentarium against AR [1, 41]. However, self medication is

very common, leading to both over as well as under-medication.

While over-medication is associated with unnecessary costs and

numerous side effects leading to increased morbidity, under-

medication leads to suboptimal control of symptoms which

hampers quality of life [1, 2, 20, 21].

Currently, oral antihistamines are usually the first group of

drugs to be prescribed in the pediatric population [1]. Since the

first generation antihistamines cause sedation, drowsiness and


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anti-cholinergic side effects [42], they are best avoided lest they

lead to impairment in performance and learning at school. The

newer second generation antihistamines, which include cetirizine/

levocetirizine, loratadine/desloratadine and fexofenadine, havenow emerged as the preferred drugs [1, 42].

Intranasal corticosteroids are the most effective form of

therapy available till date [1]. The common INCS available are

beclomethasone, triamcinolone, budesonide, fluticasone,

mometasone and ciclesonide [1]. INCS have shown to improve

nasal congestion and have demonstrated a reduction in sleep

problems and daytime sleepiness among patients [43]. This is

bound to improve quality of life during the day, reduce fatigue

and eventually improve school performance in children [2,

43]. However, dry nose, mucosal crusting and bleeding are not

uncommon [44]. Other adverse effects of INCS include transient

symptoms of nasal stinging, throat irritation, and even nasal septal

perforation [45]. Due to undue fear of systemic effects and growth

reduction, parents tend to avoid INCS for their wards. Growth

suppression in children due to INCS remains debatable though

there is some evidence of its association with beclamethasone [46].

CONCLUSION

AR, the commonest chronic pediatric disorder, is associated

with a number of comorbidities and complications and is strongly

linked with asthma. AR in children has a significant impact on the

quality of life, negatively affects the family and impairs the process

of learning. Irrational treatment in the form of under-treatment,

over-treatment as well as use of inappropriate drugs, compound

the problem. This is especially true for school going children in

whom timely and appropriate treatment could possibly avoid the

immense morbidity encountered with this disease.

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